Hemorrhoidectomy – METHODS
Closed and open hemorrhoidectomy
PROCTOLOGY – 2009
SURGICAL DIVISION CB 6 RZD – MOSCOW
The most radical method of surgical treatment of hemorrhoids is still hemorrhoidectomy surgery – excision of hemorrhoids. Nevertheless, in spite of his radical, even she can not give 100 percent assurance of the absence of recurrence in the future as well, hemorrhoidectomy directed removal of the existing nodes, but the inherent weakness of the walls of the hemorrhoidal veins, or a predisposition to constipation hemorrhoidectomy can not fix.
Hemorrhoidectomy operation in its present form was first performed at St. Mark's Hospital in 1935 by two surgeons: Milligan and Morgan, and since then it has been used worldwide for the surgical treatment of hemorrhoids.
Before the doctor chooses to open hemorrhoidectomy Milligan-Morgan, he has the fate of several factors:
Degree of hemorrhoids
Despite the fact that the operation of Milligan-Morgan can actually be used to treat hemorrhoids vnutrennenogo any degree, usually a technique used in the treatment of internal hemorrhoids second-degree nodes in the larger sizes when they are too big for the ligation of latex rings, as well as with third-degree hemorrhoids with significant prolapse of nodes.
Age of patient
In rare cases, young (under 35) of patients with severe hemorrhoids surgery hemorrhoidectomy does not guarantee long-term outcome, and therefore can come relapse. For this reason, an open hemorrhoidectomy is recommended for patients over 40 years.
Inflammatory bowel disease such as Crohn's disease, as well as immunodeficiency states (eg, AIDS) are contraindications to perform surgery hemorrhoidectomy. In addition, the cancer can not be held as hemorrhoidectomy.
Hemorrhoidectomy is also contraindicated in pregnancy, as in the following can occur during childbirth recurrence of hemorrhoids. In addition, as a rule, after pregnancy hemorrhoid goes away.
Preparation for surgery
Before you go into hospital for surgery, the patient should take some measures to normalize the functioning of the intestine. This refers to his diet, and if necessary – to receive laxatives. In addition, the doctor prescribes the patient all the necessary tests and studies to identify comorbidities. In the presence of inflammation around the anus, which often happens in patients with severe mucus, before the operation is necessary to conservative treatment (hip baths, a careful personal hygiene). Before the surgery is usually assigned laxative or enema to clean the bowel of stool.
Anesthesia for hemorrhoidectomy
Currently, surgery hemorrhoidectomy performed, usually under general anesthesia. This is due to the volume of transactions and the fact that the mere holding of a local anesthetic novocaine is painful. In addition, the "pumping" of tissue in such an already small area of the anesthetic solution, there is a violation of the ratio of anatomical landmarks, which complicates the operation. In addition, the hemorrhoidectomy can be performed and epidural anesthesia. For half an hour before the operation the patient is assigned premedication, resulting in anxiety goes away, and facilitated the introduction of anesthesia.
The procedure of hemorrhoidectomy
Open hemorrhoidectomy is usually carried out on the back, with feet fixed on the patient's special supports. Foot of the operating table is lowered (if available), or the patient himself is moving on the edge of the table. Abroad, many surgeons prefer to do this operation with the patient on his stomach with raised pelvis. In such a situation facilitated the outflow of venous blood. Once the patient lay on the table, shaving the hair is held in the anal area.
Further processing is carried out after shaving anal canal and rectum tupefarmi soaked in an antiseptic solution. Most often used an aqueous solution of betadine, as an antiseptic alcohol solutions can cause irritation if used during the operation electrocoagulator, and there is a risk of ignition. After treatment of the doctor conducting the so-called devulsiyu – expansion of the anal canal with your finger to make it easier to work with. After that, we introduce an anoscope, lubricated with sterile glycerine. Once this extended jaws and locked. Now the surgeon has access to the hemorrhoidal nodes.
After the surgeon has determined the hemorrhoids to be removed, he captures them with a special tool and pull outwards. Next clip is captured by leg haemorrhoid. Next, conducted flashing artery, which is suitable to the site. To do this, the doctor cuts the mucous haemorrhoid, reaching its base, and then stitched with a needle and thread. The common thread is held ligation feet site. To stop bleeding apply electrocoagulator. Once the artery is tied node node excised.
Possible complications of hemorrhoidectomy
- Bleeding. Most common complication after a hemorrhoidectomy. This complication may be associated with poor hemostasis (stopping bleeding) during surgery, or if, after electrocoagulation formed the "crust" on the flask disappeared. Bleeding after hemorrhoidectomy does not mean that the patient has re-formed units – is simply the result of injury to the fresh wounds after a bowel movement. For small hemorrhages commonly used a swab moistened with adrenaline, which constricts blood vessels. With more severe bleeding vessel klippiruetsya and ligated (tied).
- Retention of urine. It is also fairly common complication after surgery for men. In this case, is usually carried out bladder catheterization. Usually, this complication occurs when the patient was carried out epidural anesthesia.
- Delay feces. This is another common complication in patients after hemorrhoidectomy, which is associated usually with the fear of pain during a bowel movement. To avoid this complication, appointed by the painkillers and laxatives. And has the effect of nitroglycerine ointment, which relaxes the sphincter of the rectum. The ineffectiveness of these measures, intestinal lavage performed (under general anesthesia).
- Anal fissure. Cause of this complication can be almost healed wound injury in the rectum of solid stool. Treating it is to expand the anal canal, the use of nitroglycerin ointment or surgical excision.
- Fistula. If the allocation and excision of hemorrhoid ligature were captured in the fibers of the muscle layer of the rectum, it may cause falling back infection, chronic inflammation with formation through gradual progress from the rectum into the surrounding tissue – fistula. Usually, rectal fistulas occur after several months or even years after surgery.
- The narrowing of the anal canal (anal stenosis). This complication anal canal becomes narrowed, leading to a violation of defecation. In the early stages of this complication can be eliminated by extending the anal canal, in later cases, however, have to resort to surgery.
- Recurrence of hemorrhoids. Frequency of relapse after a hemorrhoidectomy is an average of 5%. In this case, patients may require sclerotherapy or ligation of latex rings.
- Hematoma. This accumulation of blood in the soft tissues. In this case, the blood is usually accumulates under the mucous membrane of the anal canal. A hematoma is usually emptied surgically.
- Incontinence of urine or feces. This complication is usually associated with damage to the musculo-ligamentous apparatus of the anal canal.
- Infectious complications. This complication can also occur because – remember – the operation was carried out in the area, which is constantly contaminated by bacteria.
- Prolapse of the rectum.
Open hemorrhoidectomy was named for the fact that the wounds in this operation are still open, it will heal itself.
After surgery, hemorrhoidectomy
In some cases, after hemorrhoidectomy, the patient may receive pain and urinary retention. To avoid that the surgeon does not perform anal canal tamponade, as is usually supposed. The patient is advised to drink less liquid. For relief of pain occurring after surgery is used nitroglycerin cream (0.2%), which reduces the spasm of the sphincter of the rectum. In addition, anesthetics administered injections or pills. Sometimes hip baths are recommended. However, if the patient is no violation of urination disorders, he is advised to drink more water and are appointed by laxatives, to prevent the occurrence of constipation.
After 1 – 2 weeks after the operation is carried out finger study of the rectum. This is necessary in order to check – there are no restrictions of the anal canal.
What you need to know about hemorrhoidectomy
The success of hemorrhoidectomy depends a lot on how you change your lifestyle and diet. Surgical treatment of hemorrhoids is considered the gold standard in the treatment of stage 4 hemorrhoids. It should also be remembered that not all patients show hemorrhoidectomy, and it has contraindications.
Hemorrhoidectomy has disadvantages compared with minimally invasive methods of treatment in terms of postoperative course, the feeling of pain, discomfort and the need for hospitalization. In comparison with minimally invasive procedures, treatments, hemorrhoidectomy is associated with greater risk of complications during and after surgery.
Most internal hemorrhoids improve with conservative treatment without surgical intervention. Do not just insist on surgery even less invasive methods to, if not bleeding hemorrhoid, not inflamed and does not fall out – that is, if it does not bother the patient. This is especially true if you are willing to change their diet and lifestyle.
In 1959, Ferguson and Heaton proposed a new method of hemorrhoidectomy, which can be performed on an outpatient basis – the so-called closed hemorrhoidectomy. Normally closed hemorrhoidectomy performed at the fourth and third stages of hemorrhoids with significant hemorrhoids.
Compared with open hemorrhoidectomy for Milligagu-Morgan, where hemorrhoid is excised and the wound itself remains nezashitoy that is open and closed hemorrhoidectomy for every wound that remains after removal of the sutured. The advantages of this procedure lies in the fact that after it there is no need to install the anal canal is no drainage.
As with open hemorrhoidectomy, closed with this type of operation can be complications. The most common of them – it's a pain. Also, can occur:
- The formation of an abscess,
- The discrepancy between the weld
- Urinary retention,
- Excessive swelling.
The U.S. operation is closed hemorrhoidectomy is considered the preferred treatment for hemorrhoids. However, in the long run there is a risk of recurrence of hemorrhoids, which can reach 7.5%. Then you have to resort to the minimally invasive therapies.
CENTER PROCTOLOGY Professor PROMA – GERMANY
SURGICAL DIVISION CB 6 RZD – MOSCOW
Examination and treatment in GERMANY – Institute "DIAGNOSTIX"
AID IN THE TREATMENT –
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